Transcript THE GULF COAST CENTER

FY 2014
Corporate
Compliance
& Rights Protection
Training
GAO: 3 PRIMARY
CATEGORIES OF FRAUD AND
ABUSE
 Improper billing practices:
upcoding, phantom treatment,
delivering more treatment
than necessary.
 Misrepresenting
qualifications: lapsed, expired
or false credentials;
performing outside the bounds
of one’s license.
 Improper business practices:
kickbacks for referrals to a
provider, cost report issues,
enhancement of profits by
limiting care.
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LAWS TO BE
AWARE OF
 The Federal Antikickback Statute
 The Stark Law
 The Texas Illegal
Remuneration Statute
 Civil Money Penalties
Statute
 The Federal False Claims
Act
 The Medicaid Fraud
Prevention Act
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THE ANTI-KICKBACK
STATUTE
 Applies to everyone not just
licensed staff
 “Knowingly & willfully” There must be intent to engage
in wrongful act
 “Solicits or receives/offers or
pays” – the prohibition applies
both to the offer and
acceptance of a kickback.
 “Remuneration, directly or
indirectly…” – does not require
exchanges of money just
anything of value.
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THE FEDERAL FALSE CLAIMS
ACT
 Submitting or causing to be
submitted a claim for payment
using a false record.
 Knowingly or with reckless
disregard or deliberate
ignorance of the falsity of the
claim.
 Fines can be enormous.
 Fraud Enforcement and
Recovery Act expanded FCA to
include claims to non
government payors. Creates
liability for knowingly
concealing the retention of an
overpayment.
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MEDICAID FRAUD
PREVENTION ACT
 Applies to everyone not just
licensed staff
 Knowledge or acts with
conscious indifference or
reckless disregard
 Provides a multitude of actions
that constitute fraud, including
actions by managed care
organizations.
 Penalties: Revocation of
provider agreement, Medicaid
Exclusion list for no less than 10
yrs., state license discipline, and
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monetary restitution.
PROVIDER EXCLUSIONS
DATABASE
 Any individual or entity that provides
or is involved in the provision of, or
billing for services or items
reimbursable by federal health care
programs may be excluded (MDs,
nurses, aides, PTs, billing companies,
non-licensed persons involved in some
aspect of health care industry).
 Most common exclusions include:
license revocation/suspension,
program-related convictions, patient
abuse and neglect and default on
health education loans.
 Exclusion does not expire or end on its
own terms; an individual or entity
must apply to the OIG for
reinstatement.
 Liability for using an excluded
individual or entity include:
o Civil money penalty of $10K for
each item or service claimed
o Assessment of up to three times the
amount claimed
o The violating entity could be added
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REPORTING COMPLIANCE
ISSUES
(CODE OF CONDUCT, # 14)
 As a general rule, report to your
supervisor
 As another option you may report
directly to the Compliance Officer,
Cindy Kegg
o In person at the League City office
o Phone / voice mail: 1-888-839-3229
o Interoffice mail (send to GCCLeague City)
o U.S. Mail: 4444 W. Main League
City 77573
o E-mail:
[email protected]
o FAX: (281) 338-2460

DO NOT MAKE THE EASY
MISTAKE OF FAXING
TO 388-2460
(this is a CPA Office in Alvin!)
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ACTION TAKEN IN DETECTED
COMPLIANCE OFFENSES AND OTHER
CONFIRMED CASES OF MISCONDUCT
(INCLUDING ABUSE NEGLECT AND
EXPLOITATION)
Considerations: Seriousness, Circumstances,
Work Record, Length between Violations
Possible Actions: Required Training, Written
Reprimand, Probation, Demotion, Reassignment,
Termination, Disclosures as required by Law
 Confirmed Cases of Abuse, Neglect or
Exploitation:
 Reported in CANRS
 May be reported to the Employee
Misconduct Registry, effective September 1,
2010. (Senate Bill 806, 81st Legislature)
 Compliance Offenses: May Include a
Corrective Action Plan for both the targeted
staff and the supervisor
 Reassignment may occur during an
investigation
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PROTECTING
CONFIDENTIALITY
(CODE OF CONDUCT, # 10)
You have breached confidentiality if you disclose
information to a third party who is not involved in
furthering care or does not have a legitimate need
to know.
 People included in furthering care are doctors,
nurses, social workers, service coordinators &
others directly involved in the care of the
individual.
 People not included in furthering care are those
in environmental services, personnel, patient
friend’s and family, your friends, and
colleagues not involved in the care of the
individual.
 The Mental Health Code (MHC) does allow the
release of information to law enforcement if
there is a threat of harm to self or others, or to
assist in medical evaluation or treatment.
 If your employment ends, you are still bound to
maintain confidentiality of all records and
information accessed during your employment.
 Information is not given to: family members or
friends without a release, law enforcement who
do not meet the MHC exceptions, legislature, or
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Center personnel not involved in care.
THE HITECH ACT & BREACH
NOTIFICATION
 The act defines a breach as the “unauthorized acquisition,
access, use or disclosure of protected health information
which compromises the security or privacy of the protected
health info, except where an unauthorized person to whom
such information is disclosed would not reasonably have
been able to retain such information .
 Must notify the consumer/client within 60 days of discovery
of the breach
 Notification shall include: description of what happened,
what info was involved, steps they should take, and steps we
have taken, and contact procedures for if they have
questions.
 If more than 500 people involved …must notify the media
 Requires encryption of data [safetosend]
 Red Flags for Identity Theft:
Appointment scheduling and patient registration: info looks
forged, doesn’t know DOB, physical description does not match
identifying info.
o Delivery of services: records indicate treatment inconsistent
with exam, info in record contradicts what is already known of
client,
o Consumer/client billing and questions: address discrepancies,
consumer disputes bill claiming identity theft, consumer receives
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a bill for services not received, address change that doesn’t seem
legitimate.
o Inquiries from Third Party: law enforcement, SSA notifies us
the consumer is dead, USPS informs us not an accurate
address, contact from an insurance fraud investigator
o
HIPAA...STAFF ACTIONS
Employees access PHI only to the
degree necessary to perform their
jobs.
 Staff should only have access to PHI
regarding the consumers that they
are working with, not other persons
receiving services
 Any staff persons outside the
interdisciplinary team working with
a consumer probably do not have a
need to know PHI about the
individual
 If you are unsure of who to release
information to, DON’T RELEASE
IT!!! Check with your Supervisor, or
Linda Bell, Director of Legal Affairs.
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Staff Actions
Employees have a duty to safeguard PHI
from intentional or unintentional use of
disclosure that is in violation of the
HIPAA Privacy Rule by…
 Keeping records locked up when not in use.
 Users should log off their computers while
away from their desks.
 Computer screens should not be in plain
sight
of public
 Written information in nurse stations, desks,
etc., should be covered from public view.
 Discussions about consumers should be
made
in private, away from public areas.
 Electronic records should be kept secure.
Facilities should monitor who accesses PHI.
 Paper records should be shredded and never
left in the garbage for disposal with
regular trash.
 Do not share your computer password
with anyone. Create a password that is
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unique and difficult for someone else to
guess.
Do not write it down where someone else
can see it or find it.
Staff Actions
Employees refer requests for
PHI, requests from persons
served to amend records, and
related
requests
to
the
appropriate office.
 All requests made by consumers
should be reported to Liz Bennett,
Technical
Assistant
Medical
Records Administration, located
at Southern Brazoria County
CSC:
o
o
o
Direct line: (281) 585-7389 or;
SBCSC (979) 848-0933
x11313
Fax: (979) 848-0937 (call to
confirm receipt of fax)
 If you receive a subpoena, court
order, or a request for an affidavit,
notify Liz Bennett immediately.
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Staff Actions
Employees report or assist others in
reporting suspected privacy rights / HIPAA
violations
 If an employee or consumer wishes to
make a complaint about The Gulf Coast
Center, call or refer them to:
o Cindy Kegg, The Gulf Coast Center’s
Rights Protection Officer/Corporate
Compliance Officer
o TDSHS or TDADS Office of Consumer
Services and Rights Protection
o U.S. Department of Health and
Human Services
o Texas Attorney General’s Office
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CONSUMER / CLIENT
RELATIONS
(CODE OF CONDUCT # 12)
 All consumers/clients deserve to
be treated with dignity and
respect and have the right to be
involved in their care. Dignity
and
respect
includes
the
elimination
of
prejudicial
language.
 It is the responsibility of each
employee to ensure that the
rights of clients are protected.
 Each employee must familiarize
themselves with rights set forth
in policy, procedures and in the
rights protection handbook.
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FORBIDDEN CONSUMER EMPLOYEE RELATIONSHIPS
(CODE OF CONDUCT # 12)
Dating
Implied Sexual and Sexual in Nature
Contacts (i.e., physical act, telephonic and
electronic)
No Living Arrangement Agreements
No loans or storing/holding of Consumer
Funds/Money
Staff may accept no monetary gifts. Policy
does allow acceptance of gifts of <$50.00.
Recovery programs can not accepts gifts,
monetary or otherwise
Consumers can not do chores (i.e. picking up
trash or cleaning restrooms) for cigarettes or
other privileges; this is a violation of the
Department of Labor
Caution: Telephone communications should
be limited to Center Business due to
misinterpretations of others.
Caution: If a consumer/client has a business
and you would like to bid for his services or
have him do some work for you do realize that
there may be some ramifications for such
action. The relationship may appear to have 17
some form of exploitation.
Caution: Avoid the appearance of
inappropriate behavior.
PREVENTING ABUSE,
NEGLECT AND
EXPLOITATION
 Learn your Job
Understand expectations
and focus on doing your job well.
 Communication
Don’t take your anger or
frustration out on persons served or their
families. Do your part to help foster
positive relationships with co-workers
and
keep morale high.
 Stress Management
Manage your stress
levels.
 Personal Problem Management
Leave
personal problems outside of the
workplace. If you are having difficulty
with
this, speak to your supervisor. Seek help
if
you need it!
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RECOGNIZING SIGNS /
SYMPTOMS OF POSSIBLE
ABUSE
(CODE OF CONDUCT # 12)
 Multiple scratches, cuts, bruises,
burns
 Unusual patterns of injuries
 Inadequate or illogical explanation
of injury
 Serious injuries: sprains, breaks,
bedsores


Reports of confinement

Passive, withdrawn behavior with
certain people
Reluctance to participate in physical
exams
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RECOGNIZING SIGNS /
SYMPTOMS OF
POSSIBLE NEGLECT
(CODE OF CONDUCT # 12)
 Lack of food or malnourishment
 Lack of water or dehydration
 Withholding
meds/overmedicating
 Inadequate shelter
 Unsanitary living conditions
 Untreated health problems
 Lack of personal
hygiene / clothes
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EXAMPLES OF
EXPLOITATION
(CODE OF CONDUCT # 12)
 Taking, holding, borrowing money
(even if the money was paid back)
 Taking Social Security /SSI checks
 Taking property
 Exchanging items of unequal value
 Requesting items to be
for
staff
purchased
 Using consumers as free labor
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REPORTING ALLEGATIONS OF
SUSPECTED ABUSE, NEGLECT
OR EXPLOITATION (MH & IDD SERVICES)
 ALL staff have the responsibility to report
 the staff in receipt of the information should
make the report
 DO NOT contact co-workers, your
supervisor, or the Rights Protection Officer
and ask his/her opinion on whether or not
to
report. THE DECISION IS YOURS!
 refer to the definitions of abuse, neglect and
exploitation
provided
in
this
training
(CANRS)
 Immediately (within 1 hour) make a report to
DFPS via the website or statewide intake phone
number:
o www.txabusehotline.org
o 1-800-647-7418
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 If the alleged perpetrator is a Center staff or
contract staff, complete an Incident Report
within 24 hours and fax/scan to RPO
REPORTING…CONTINUED
DO NOT notify the alleged
perpetrator of the impending
investigation.
DO NOT conduct a miniinvestigation.
DO NOT discuss the incident
with others.
 DO preserve the safety of the
person and arrange for
emotional support or medical
care as appropriate
 DO protect any evidence (i.e.
take pictures, secure the
record, etc.)
 DO cooperate with DFPS 23
investigators
WHEN YOU MAY NOT
RELEASE INFORMATION ON
A CENTER CLIENT
The “Interpretive Guidance on Laws
Pertaining to Privacy of Mental Health and
Mental Retardation Records for the MHMR
Service Delivery System” pursuant to the
TAC Protected
Health
Information,
Chapter 414, Subchapter A, states:
§ When Authorization is not Required
to Use or Disclose Protected Health
Information that Relates to MHMR
Services
(b) When required or authorized by law
(3) A component may disclose PHI to
the Department of Family and Protective
Services) when necessary to report or
cooperate in the investigation of suspected
child abuse or neglect.
However, the PHI of a parent
or other person responsible for the
care of the child who is the subject24
of the report or investigation may
only be disclosed pursuant to a
court order.
What Happens When a
DFPS Investigation
Occurs?
DFPS receives a report (website or
1-800 number)
Notifies RPO
RPO notifies
ED, Review
Committee,
Supervisor
Request
for Review
forwarded
to
Assistant
Commissioner of
APS
APS initiates an investigation
APS mails completed
investigative report to RPO upon
completion
Copy of report given to ED, Review
Committee and if confirmed, to staff;
Case reviewed
Agree
with
finding
s
Disagree
with
findings
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Case
Closed
INCIDENT
REPORTS…WHEN TO
REPORT
(CODE OF CONDUCT #15)
• Actual or suspected
abuse, neglect or
exploitation /other
rights violations
when a staff person
is the alleged
perpetrator
• Vehicle Accidents &
Injuries(client or
staff) Report
immediately to
• James Rollens III
• at 713-545-7595
• Violent behavior
• (client or staff)
• Threats or acts of
aggression (client
or staff)
• Destruction /loss
•
of property (client
or staff)
• Illegal behavior
(client or staff)
 Medical emergencies
 Psychiatric
emergencies
 Serious infraction of
program rules (client
or staff)
 Loss of consumer
record
 Use of personal
restraint
(if not part of
approved Behavior
Plan)
 Missing consumer
 Death of consumer
 Fire
 Violations of the
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Business Code of
Conduct, as
appropriate.
 EMAILS W PHI
INCIDENT REPORTS
…PROCEDURES
 The following reports 
must be submitted to 
the RPO within 24

hours:
1) abuse/ neglect/
exploitation/ other
rights
issues (when staff is 1)
the
alleged perpetrator)
2) deaths (active
clients)
3) incidents involving
workman’s comp (also
fax to Ricki at
Admin!)
All other reports must
be submitted to the
RPO within 48 hours
Write legibly
Fill in all appropriate
blanks
Include your
response /
follow-up to incident
then…

Fax to RPO in League
City: 281-338-2460 /
Send original to
RPO
immediately, OR
2) Submit electronically

REMEMBER, 27
Do not keep a
copy or put a copy